Comments on the paper of the AG Pflege

In advance

The context of the definition of quality should not be sought in care, but where the word "quality" is used.

You can talk about quality in many contexts: in philosophy as a quality or essence. Quality as the opposite of quantity or when quantity is to be transformed into quality. In types of material (Manchester-quality cloth) or in medicines, whose pharmaceutical quality is important.

For this reason, I recommend that you first name the context in which "quality in care" is to be discussed here.

For the working group of a professional association, only the context of "quality management" comes into question if it wants to "define quality".

QM always talks about the quality of

(1) Products or (services) that are created by a provider (here: the carers) for someone (here: people in need of care). In this respect, they are always "customer-centred".

(2) This includes a certain organisational framework. The service must be provided by several people working together. It makes no sense to speak of QM when care is provided by a single person.

(3) The context also includes the fact that the service is always provided in return for a service (exchange). This is correctly emphasised in the working group's paper as a distinction between professional and lay care. The latter can also be good or bad. You can also make demands on compassionate services. However, it is not possible to sue for their fulfilment.

Talking about "quality in care" only makes sense in the context of professional care. It offers definable individual services that are often bundled into larger complexes. It is the result of institutional co-operation (hospital, nursing home, nursing service, etc.). It is based on professional training. It is paid because the service providers base their livelihood on it. QM serves to organise the provision of services in such a way that the requirements of those for whom they are provided are met - nothing else makes sense. Sometimes it is necessary to prove that the result has been achieved.

In order to practise QM, you need to know what is meant by quality.

Logical.

Comment 1

The IOM's definition (1990!) is inadequate. It has three serious errors:

• It mentions health services for individuals and for populations in the same breath. However, what comes out with "desired health outcomes" are very different outcomes. In an epidemic, we use nursing services to treat individual patients and measure success on an individual patient basis. That is patient-centred. Measures that are focussed on the population are completely different. The result is measured by statistical figures - the individual person does not appear because these measures are population-centred.

Care is always patient-centred, never population-centred. We can therefore safely leave out the population aspect here.

• If you read carefully, you realise that it is not quality that is being defined, but effectiveness. Effectiveness is the characteristic of a service that increases the probability of a desired event. In other words, the IOM definition reduces quality to effectiveness. It was not until 10 years later that this error was corrected by the "To Err Is Human" report. Safety is at least as important as efficacy. For this reason alone, K. LOHR's 1990 definition should finally be discarded.
• The services should be "consistent" (compatible, not contradictory) with professional knowledge. But what is professional knowledge? Who determines that? Isn't it constantly changing? What about innovation? On the face of it, this part of the definition is outrageous: the services must not contradict the opinions of the (medical?) profession. Florence Nightingale wouldn't have stood a chance.

Today we say: they must be evidence-based. However, this means something different: the statements about the services (how effective, how safe or acceptable they are) must be based on evidence. "Evidence-based" is therefore not a quality feature of the service, but of the statement about services. If grandma recommends caraway tea to me for constipation because her grandma already recommended caraway tea, then that is not evidence - but it can still be very effective, safe anyway, but less acceptable (unpleasant) because of the taste. But we have no evidence for this, just grandma's word.

Comment 2

Unfortunately, the IQTIG has adopted three errors and added one:

• The care of populations is population-centred. The care of individuals is patient-centred. One thing is only possible at the moment. The care of populations is not patient-centred. But nursing care only needs to remove this point. It is never population-centred.
• After all, the IQTIG definition adopts a formulation from DIN EN ISO 9000:2015: the "fulfilment of requirements". But how can you tell whether the requirements are met? You can't find out. The ISO, on the other hand, clearly states that the characteristics of the service must fulfil the requirements. Not just one characteristic, but a "set of characteristics". "A set of" means characteristics that belong together but may not be offset against each other.

ISO 9000 refers to the service or product as the object of consideration in very concrete terms - the individual care services, not an abstract collective term such as "the" care. "Care of individuals" is the term for a set of nursing services, each of which may or may not fulfil requirements. Because the IQTIG definition leaves the object of consideration as "care" undefined and the "set of characteristics" undefined, the definition is tainted.

• The IQTIG definition adds a further error: whereas in the IOM definition the "health services...must be consistent with current professional knowledge", in the IQTIG definition the requirements should be "consistent with professional knowledge". Whatever "consistent" means - one thing must be clear: Requirements are not dependent on knowledge. If I have the requirement to be cured of my cancer, but the doctors tell me that there is currently no effective cure, then they are right - but this does not change my requirement.

Comment 3

Whether you call the person for whom a care service is intended a patient or a resident is left to common parlance. In a hospital it is the patient, in a residential home it is the resident, in nursing care it is the person being cared for. Or, analogous to the vaccinated person (the person to be vaccinated), perhaps the carer? We are still struggling to find a suitable term. "Person in need of care" is exactly what is meant, but it is neither a common nor a particularly attractive term.

Comment 4

The term "patient safety" has become established. However, it conceals the fact that it refers to the safety of the services for the patient. Safety is a characteristic of the service, not of the patient. It would therefore be more correct to protect patients from the uncertainty of medicine. Very well. Everyone knows what is meant.

I find the distinction between avoidable and unavoidable adverse events (AEs) unwise. Even supposedly unavoidable ones are undesirable and can be quite unpleasant. A procedure in which more "unavoidable" AEs occur is simply less safe than one with fewer. A procedure in which these are avoidable is then better.

Comment 5

I would always speak of characteristics, not dimensions. That would be technically correct. The diagram also mentions characteristics. The term "dimensions", as used by Donabedian and, with reference to him, also by the IQTIG, is uncommon in QM and contradicts common usage. Or who calls efficacy and safety "dimensions" of a medicinal product?

Comment 6

Everything that follows from here deals with the problem of providing services under difficult conditions and how quality would be possible with limited resources.

All this is no longer part of the concept of quality, but of the conditions under which attempts are made to fulfil the requirements. I propose deleting these paragraphs.

But perhaps this would be a good place to explain the idea of the claim class.

The "conclusion" is still very confusing and not always grammatically correct.

The summarised presentation as a definition in the penultimate paragraph does not meet the requirements for a definition. It does not properly take up what was said before. This also applies to the last paragraph. I would not allow these two paragraphs to go out without revision.

While working through the document, I have edited the text considerably. Perhaps you will like one or the other.

Fahrdorf, the 2020-04-09
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